1.

At its triennial congress in Yokohama last September, the World Psychiatric Association (WPA) overwhelmingly voted to send a delegation to China to investigate charges that dissidents were being imprisoned and maltreated as “political maniacs” both in regular mental hospitals and in police-run psychiatric custodial institutions known as the Ankang. (The word literally means “Peace and Health.”)

The WPA’s vote was a direct result of Dangerous Minds, written for Human Rights Watch and the Geneva Initiative on Psychiatry by Robin Munro, and one of the most revealing books about China in many years. Many of the leading figures in the WPA acknowledge that Munro’s ground-breaking research lies behind the association’s negotiations with Chinese psychiatrists over the last year and its decision to send a delegation to China. What Mr. Munro’s eloquent and convincing study reveals is that from the 1950s onward not only Chinese dissidents but people who submitted petitions to the authorities have been detained by the police, examined by psychiatrists, and found to be criminally insane—or, if found mentally “normal,” designated as criminals to be cast into the prison system.

Once in China the members of the WPA delegation intend to visit several of the secret Ankang mental hospitals where dissidents are confined—they are in more than a dozen large cities—and to form their own professional judgments of the conditions of the inmates. It would be useful, although it is unlikely to happen, if the delegation were able to come face to face with some of the inmates described in Munro’s book.

The Chinese Society of Psychiatrists (CSP) is a member of the WPA, which represents psychiatric organizations in 119 countries, with 150,000 psychiatrists. China is bound, in principle, to adhere to the articles of the association’s 1996 Madrid Declaration, which forbids introducing political judgments in psychiatric diagnosis.

But a question immediately arises: Will this Western-dominated medical association, which has been mainly concerned with professional standards and behavior, be any match for an authoritarian government that puts security, order, and secrecy before human rights? Both the WPA’s past president, Juan Lopez-Ibor, in his visit to China last February, and the vote last September in Yokohama made it plain to Beijing that psychiatrists throughout the world want the WPA to conduct a thorough investigation of the allegations of psychiatric abuse. But in its official statements about contacts with Beijing the association is proceeding cautiously, if not timidly. It is essentially limiting the concerns of what the CSP calls its “educational” visit next year to China to treatment of the members of Falun Gong, the religious and meditative group that since 1991 has been proscribed as criminal. Its members, when imprisoned, are often treated as criminally insane.1

The WPA’s self-imposed limitation ignores the hundreds of political dissidents who are confined in the Ankang psychiatric hospitals run by the public security organs and who are the main subject of Munro’s book. The psychiatrists who staff these institutions, Dangerous Minds shows, tend to assume that their patients are mad because of their political beliefs or actions. The diagnoses made in both the political dissident and Falun Gong cases, ranging from “delusions of reform” to “paranoid psychosis,” are highly reminiscent of the long-discredited label of “sluggish schizophrenia” that the Soviets used to apply to their dissidents and religious nonconformists.

At the Yokohama meeting, according to one report, “Lopez-Ibor said the team must have the right to inspect wherever and whenever it wants.” But he also conceded that China has the final say. “We don’t have the possibility to visit all the hospitals one by one,” he said. “We need some green lights from the Chinese health authorities.”

“What we want is that the people who go have the freedom to do what they want,” he told Reuters. “It would be a disaster if the [mission] goes there and comes back with more questions than answers.”

It is, however, unlikely that visits will be permitted except under tight control by Beijing, which has officially denied as “sheer nonsense” the allegations of Human Rights Watch and the Geneva Initiative. On October 4 the official New China News Agency, Xinhua, stated that

the State Council Information Office held a press conference at which it rejected as a “vicious slander” claims at “international conferences” that China has used psychiatric treatment to perse-cute “dissidents” and “Falun Gong followers.

This statement will make it still harder for the WPA to insist that it be permitted to interview detainees in the Ankang during any visit it makes. Asked if China had received a request from the WPA to send a mission, the Foreign Ministry spokesman said, “No. I have not heard about this.” The spokesman was either lying or unaware of the facts. According to an internal WPA memorandum circulated at the Yokohama meeting, “The WPA President met in Beijing in early 2002 with the CSP and with the Chinese Deputy Minister of Health.”

Robin Munro, a key figure at the Yokohama congress, is the preeminent researcher in the field of Chinese human rights. He is the coauthor of a thoroughly documented exposé, which Beijing condemned, of the shocking state of Chinese orphanages, and a comprehensive directory of political and religious prisoners, both published by Human Rights Watch. Dangerous Minds is his most impressive work to date. It documents more than fifty years of political repression and what many international medical experts strongly suspect is politically motivated psychiatric malpractice. Dr. Paul Appelbaum, president of the American Psychiatric Association, told me recently: “But for Robin Munro’s work, none of this would be happening. Munro is the only person to have presented persuasive evidence on the basis of which action could be taken.”

Well before the Yokohama congress, in July 2001, Britain’s Royal College of Psychiatrists resolved that

bearing in mind the available evidence that political dissidents in the People’s Republic of China (PRC) are being systematically detained in psychiatric hospitals… the World Psychiatric Association [should] arrange a fact-finding visit to the PRC.

This resolution was presented at Yokohama but not voted on. It was evidently regarded by the WPA’s leaders as too harsh in advance of the visit to China supposed to take place next year.

This is the WPA’s conundrum. Its leadership is keen to avoid the uncertainty and timidity which for years prevented the organization from confronting the Soviet psychiatric persecutions, which continued into the late Eighties. Dr. Lopez-Ibor insists that the WPA action on China “is not comparable at all with the Soviet issue in which the confrontation between the WPA and the All Union Society of Psychiatrists and Narcologists was total.” In a letter to me he wrote:

The Chinese Society of Psychiatry is collaborating with the WPA Review Committee in collecting the information. They have gathered data on the cases of the Munro book plus a list of over 200 other cases submitted by the WPA. This information is now being considered by the WPA Review Committee. The Chinese Society of Psychiatrists has accepted the ethical principle of the WPA as stated in the Declaration of Madrid.

In his letter Dr. Lopez-Ibor stressed that Falun Gong will be the focus of the WPA investigation. “As you see, the process of analyzing the alleged cases of abuse of psychiatry on Falun Gong practitioners is open and…the WPA has [so far] been able to get support from our local Member Society,” i.e., the Chinese Society of Psychiatrists. In other statements, the WPA speaks of five hundred Falun Gong cases. “Up to this point, we have had good cooperation with the Chinese,” according to Dr. Marion Kastrup, outgoing chairman of the Committee for the Review of Abuse of Psychiatry and director of the Institute for Trans-Cultural Psychiatry in Copenhagen. “We have to look at files and talk with persons. We must obtain entry to China and permission to study whatever we need to study.”

Dr. Lopez-Ibor’s and Dr. Kastrup’s assurances do not fill one with confidence. While members of Falun Gong are indeed detained in mental hospitals in large numbers, it seems unjustifiable for the WPA to exclude virtually all the other political detainees about whom Mr. Munro provides so much evidence. For the past twenty years psychiatric malpractice has, according to Munro, concentrated on at least three thousand political dissidents. Munro derived this figure, which he thinks is probably too conservative, from numerous officially published studies and statistics on “political cases” dealt with by Chinese “forensic psychiatrists”—i.e., psychiatrists concerned with applying the law—since the late 1970s.

As for the current negotiations, Munro pointed out to me that the Chinese Society of Psychiatrists is relatively powerless compared to the Chinese government’s Public Security Bureau, which does most of the actual psychiatric committals of dissidents and Falun Gong activists. The Chinese government’s single-minded objective, in Munro’s view, is to deny all the allegations, “disprove” them by means of a controlled WPA mission (if such a mission takes place), and thereby win the public relations battle. Professor Arthur Kleinman of Harvard, a leading expert on Chinese psychiatric practice, told me that Ankang visits will not take place because the authorities will not permit them. Dr. Mike Shooter, the president of the Royal College of Psychiatry, which said last year that the visit must be “an inspectorate and not a collegiate one,” told me:

If the Chinese government refuses any part of the WPA protocol for a truly open visit [i.e., by a team chosen by the WPA, independent of the Chinese government or local organizations, and with free access to inspect any institution or talk to any person they wish] then I personally feel that the WPA should call an extraordinary meeting of its member organizations or their representatives specifically to discuss what action it should take.

Robin Munro, mindful of how long it took the WPA to expel the Soviet Union’s psychiatrists, is aware of the organization’s difficulties in dealing with one of its members. “The important thing,” he told me,

is to remember that the WPA has been mandated by the entire membership at Yokohama to conduct a full investigation; they have their own Madrid Declaration breathing down their necks, and they have to report back on progress at the American Psychiatric Association’s annual meeting in San Francisco next May. If they can’t give the right answers, such as whether or not they actually had access to Ankang facilities, or indeed to any psychiatrically detained dissidents or Falun Gong activists so they could be independently medically examined, but at the same time try to claim that they’ve received full cooperation from the Chinese side in the investigation, they’ll be heavily criticized at San Francisco. The British and American member societies would probably insist that China’s continued membership in the WPA be opened up for reconsideration. It would take some time, but in the end China could well be expelled from the WPA on the grounds of manifest non-cooperation in the investigation.

It is important to be clear about what is and is not known about Chinese practice. The details of what happens to political or religious dissidents once they enter an Ankang are scarce. According to an account given to Munro in 1987 by a former prisoner at a Shanghai facility, inmates were punished by intravenous injections that made their tongues bulge out of their mouths and by extremely painful acupuncture which applied an electric current to the sole of the foot. But whatever further inquiry may show, the fact that dissidents are sent to an Ankang, diagnosed there as “political maniacs,” and imprisoned, according to official sources, for an average of five years is a violation of their human rights and of the international medical standards which China insists it follows. According to Chinese psychiatric documents cited by Munro, by 1992 the total number of Ankang hospitals had risen to twenty, with several others under construction. According to one source, large Ankang centers can accommodate around one thousand inmates; the Tianjin facility, however, is now believed to have around twice that capacity. According to another official source, some inmates are being held for as long as twenty years. The government’s eventual goal is to establish one Ankang center for every city in China with a population of one million or above.

2.

One of the main categories of “people taken into police psychiatric custody” for diagnosis, according to an official police encyclopedia cited by Munro, are those

commonly known as “political maniacs,” who shout reactionary slogans, write reactionary banners and reactionary letters, make anti-government speeches in public, and express opinions on important domestic and international affairs.

In 1994, a case of what a senior official termed “utter political lunacy” was published in a training manual for Chinese forensic psychiatrists. According to Munro’s account in Dangerous Minds, “Zhu,” fifty-seven, an army veteran, Communist Party member, and retired worker, had been diagnosed as a “paranoid psychotic” and probably confined in one of China’s special Ankang. Although Zhu had been praised in the official newspaper People’s Daily as a model activist during the Cultural Revolution, by the Eighties, still an ardent Maoist, he spoke and wrote against Mao’s successor, Deng Xiaoping. His workmates regarded Zhu as quiet, respectable, orderly, and sane, although somewhat eccentric; he never discussed his “reactionary” views with them. He wrote a 100,000-character manifesto, bought a printing machine, and sent his views to various leaders.

Psychiatrists found Zhu “politically deluded,” and deemed his views and writings “incompatible with his status, position, qualifications, and learning” (he was, after all, a mere semi-educated worker, and hence seen as not being qualified to speak on politics and economics—despite having held a leading position on his local Revolutionary Committee). They declared that he was “divorced from reality,” although his delusions were said to be “not entirely absurd in content,” and his “overall mental activity remained normal.” His fate in the Ankang is unknown, as is almost always the case.

In another case, a “female,” age forty-five, described in the Chinese Journal of Clinical Psychological Medicine in 2000, was arrested for being a member of Falun Gong and practicing the qigong exercises which Falun Gong claims improve spiritual understanding and health. Until 1999 Falun Gong was praised as beneficial in mainstream Chinese medical journals, and high officials were among its millions of practitioners; its influence and membership have spread abroad. In 1999, after ten thousand Falun Gong members participated in a silent vigil outside the Beijing compound where China’s top leaders live and work, the group was condemned as a “heretical cult organization” (the term was also used in Confucian times for ideologically heterodox sects and superstitions) and an “evil cult.” Thousands of adherents were imprisoned and some three hundred were reportedly confined in mental hospitals.

The only “mentally dangerous” symptom or activity cited in the forty-five-year-old woman’s police psychiatric report was:

Even after the government declared Falun Gong to be an evil cult, she refused to be dissuaded from her beliefs and continued gathering people to practice Falun Gong.

Moreover, she went to Beijing to petition the authorities “about the suppression of the group.” She was then “placed under criminal detention.” Her official diagnosis: “mental disorder caused by practicing an evil cult.”

While Munro is explicit that his book is not an indictment of Chinese psychiatry as a whole (most Soviet psychiatrists also behaved ethically), he shows in detail that psychiatry is being used as an instrument of political persecution. Neither Zhu nor the woman who joined Falun Gong would be deemed criminal in a Western democracy, and it is most unlikely that they would be viewed as mentally ill by a Western psychiatrist. In both cases a serious sign of their “mental disorders,” frequently cited in similar Chinese psychiatric diagnoses of political or religious “crime,” was that, unlike what are called “genuine dissidents,” the accused made no attempt to “disguise their identities or run away.”

3.

Chinese psychiatry has come under increasing professional scrutiny largely because of the earlier Soviet persecution of dissidents in mental institutions. After the dissident Vladimir Bukovsky sent documentation of Soviet cases of extremely harsh abuse to the World Psychiatric Association in 1971—and was imprisoned for twelve years—the Russians threatened to leave the WPA. This cowed the association into inaction until the Dutch-based Geneva Initiative on Psychiatry, one of the co-publishers of Dangerous Minds, and the British and American psychiatric associations became interested in the abuses in Soviet psychiatry. Many psychiatrists, however, feared that they were becoming involved in a political issue rather than an ethical one—a fear still present among psychiatrists about China, although as Robert Van Voren, head of the Geneva Initiative on Psychiatry, writes, those condemning the Russians were aiming “at taking politics out of psychiatry, rather than at bringing it in.”

At the 1977 WPA meeting in Hawaii the evidence of Soviet psychiatric repression was at last openly discussed, with the result that the Declaration of Honolulu set out psychiatric ethical standards condemning politically based diagnoses. In 1983 the Soviets, about to be expelled, withdrew from the WPA and were not readmitted until 1989, after the Gorbachev reforms began, when their psychiatrists finally admitted the abuses and slowly set about correcting them. In 1996 the WPA issued the Madrid Declaration, which lays down international psychiatric ethics and practices further strengthening the ban on political diagnosis. It has taken only a year to get China on the association’s agenda but unfortunately the WPA’s approach has been ultra-cautious; only vigorous investigation will expose the truth.

In China, as Munro explained to me,

Our main problem is that we don’t have specific case information on more than a few political detainees in mental asylums in China, although we have over three hundred named Falun Gong case accounts of this type. However, we have a wealth of official reports from the PRC psychiatric literature making it blindingly obvious that numerous political dissidents are being incarcerated in asylums when they shouldn’t be.

Because they’re held indefinitely in the highly secretive police-run Ankang system, we usually don’t know their names. But this surely makes it all the more vital that the WPA should include the political dissident detainees within the scope of its investigation and insist on gaining access to the Ankang.

Aside from those Munro mentions, other well-attested cases vividly show how Chinese dissenters are mistreated by psychiatrists. Cao Maobing, who two years ago attempted to organize his fellow workers at a state-owned silk factory into a trade union—an illegal act—is a good example. He was sent to the No. 4 psychiatric hospital in Yancheng, the day after he spoke to Western reporters. His fellow workers, according to an American who knows Cao, described him warmly: “Mr. Cao is an upright, kind, and law-abiding citizen. He is a brave and intelligent worker. He made a lot of personal sacrifice to help other workers to uphold their right to basic living.” Cao’s wife said he was being forcibly medicated. “He’s absolutely not insane and refuses to take the medicine. But eventually they force him to take it.” She said she was told to leave the hospital after her husband was medicated. According to other reports, he was also given electroshock treatment on several occasions. Cao was released after six months and has never returned to trade union activity.2

The current doctrine justifying such treatment can be found in the views of Liu Baiju, a researcher at the Chinese Academy of Social Sciences, who proposed in 2000 the new diagnostic category “negative political speech and action” as a substitute for “the currently prevalent notions of mentally pathological ‘counterrevolutionary behavior’ or ‘behavior that endangers state security.’” In fact, accusations of negative speech and action led to the detention of some of the Chinese citizens I have mentioned here. Mr. Liu includes as threats to the state carried out by mentally ill people “writing of banners, distributing leaflets and flyers, sending letters, making speeches, and shouting out slogans.” As his account also makes clear, his somewhat more liberal-sounding formula of “negative political speech and action” is of no practical help whatever for the detainees concerned. Since they are still deemed to have committed serious political crimes, they must be sent to high-security mental hospitals or institutes for the criminally insane, just as before.

According to a study by Professor Liu Xiehe, one of China’s most progressive forensic psychiatrists, who was present in Yokohama, the psychiatric appraisers who work in the judicial system

make a presumption that the person being examined is either mentally abnormal or afflicted by some form of mental illness. They assume that the examinee would not have been sent for appraisal [by the police] in the first place unless he or she was in fact mentally abnormal or suffering from mental illness.

As in all such Chinese procedures, whether medical or judicial, it is only very rarely that people are found innocent.

Munro writes that there are brave Chinese psychiatrists who have openly opposed such procedures, and have suffered for it. One of them is Dr. Yang Desen, himself a victim of the Cultural Revolution, who is now a leader in efforts to bring about humane psychiatric reform. As early as 1978, sometimes in explicit conflict with Maoist psychiatrists, he observed that “mental illness knows no class boundaries or divisions.” Working people in large numbers suffer from mental diseases, Dr. Yang said, and it cannot be claimed, as Maoist doctors did, that mental disease is a bourgeois, capitalist disorder.

In 1983, Dr. Yang and his colleagues found that in a hierarchy of forty-three factors leading to “mental disturbance,” after the death of a spouse or other main family member, the third most common cause was “being attacked in the course of political movements.” For many Westerners this must in itself seem an insane statistic. But in China, where there is a fifty-year history of citizens being persecuted by the Party-state, and by fellow citizens doing the bidding of the state, it is only too believable that people can be driven mad by other citizens.

Chinese forensic psychiatry, Munro shows, was used to detain strikingly fewer political prisoners during the first decade or so after the Cultural Revolution; the number rose again at the time of Democracy Wall in 1979 and again after 1989 as Tiananmen demonstrators and sympathizers in hundreds of cities were caught up in the vast national qingcha, or ferreting-out. The numbers detained by forensic psychiatrists declined again in the early 1990s. But with the persecution of the Falun Gong, beginning in mid-1999, tens of thousands were detained, arrested, charged, imprisoned, and sometimes tortured—and several hundred were sent to mental hospitals. The number of those detained is now so high that many are confined in ordinary mental hospitals rather than the Ankang institutions in which apparently there is not enough room.

Such is the nature of Chinese official secrecy that a serious investigation of the Ankang has never been possible, and the WPA is unlikely to succeed where other more powerful bodies have failed. For years, for example, the International Red Cross and the UN’s Human Rights Commissioner Mary Robinson have been trying to gain unrestricted entrance to Chinese pris-ons, so far with no success. Professor Arthur Kleinman, who believes the WPA should send a study committee to China, warns that its achievements will be limited. The visitors, he told me,

will never see the inside of an Ankang unless the Chinese have cleaned it up first. But they should go anyway. The Chinese know they’re getting a black eye about this political psychiatry and they know there are hacks in the Ankang. This WPA visit will probably have an effect on raising the standard of forensic psychiatry. But the WPA delegates are kidding themselves if they think they are going to ferret anything out. I hope that when the group returns they report that they think there are big problems in certain aspects of Chinese forensic medicine and that the WPA would like to help raise the standard. One of the ways that could be done is to find the funds to send Chinese forensic psychiatrists to the best centers in the West.

In 1989, Dr. Semyon Gluzman, a Soviet psychiatrist imprisoned for seven years in a strict labor camp for speaking out against political abuses in mental hospitals, proposed three methods for research into such malpractice. The first was to medically examine independently those accused of having committed political crimes while insane; the second was to examine psychiatric theory and practice applied by the Soviet profession; the third method, described by Dr. Gluzman as “very complex and laborious,” rests on the examination of an

enormous number of Soviet psychiatric publications. The advantages of such an approach are self-evident: no “discovery” can be disputed and such “content analysis” will inevitably show who abused their profession and when.

What Dr. Gluzman recommended remains true for China, and his third method has been used by Robin Munro in his path-breaking book. Whether the World Psychiatric Association, armed with the evidence Munro has provided, will strongly press the case against the psychiatric abuses in the Ankang seems unlikely. But as Dr. Gluzman rightly said, “This work must be done: real people, victims of abuse, need protection and help, not academic discussion about humanism and justice.”